EMS Disaster Planning and Operations

Issues of Concern

In the 1970s, a standardized system for responding to disasters, the National Interagency Incident Management System (NIIMS), was developed and widely adopted by the early 1980s. (Source: Manzello, 2020) This system remained in use until after the September 11, 2001, attacks. The Department of Homeland Security was established in response to these events, and Homeland Security Presidential Directive 5 mandated a comprehensive system for managing incidents across the US.

The development of this comprehensive program by FEMA involved contributions from local, tribal, state, and federal stakeholders, as well as nongovernmental organizations, emergency response agencies, and private-sector partners. The process resulted in a consolidated document outlining best practices from across the country. The National Incident Management System (NIMS) was subsequently created by integrating elements of both the FIRESCOPE Program and NIIMS. (Source: Neville and Neamy, 2011)

NIMS provides a structured framework that enables agencies from multiple sectors to coordinate during disasters. The system is adaptable to incidents of all scales while maintaining a standardized approach to incident management. NIMS is organized around 5 core components: preparedness; communication and information management; resource management; command and management; and ongoing management and maintenance. The ICS constitutes a key component within the command and management element.[5][6][7][8]

ICS addresses many of the problems encountered in previous disasters. Several ICS principles specifically target interoperability difficulties observed in past responses. (Source: ChrisberGen Blog, 2025) 

A modular organizational structure was developed to manage disaster responses. This structure is built from the top down and can be expanded or contracted to accommodate incidents of any scale. ICS requires that event management be driven by clearly defined incident objectives, with personnel assigned to specific tasks to achieve these objectives. The incident action plan formally communicates these objectives.

The span of control, defined as the number of personnel supervised by an individual, is typically limited to 3-7, as effective leadership and supervision become challenging beyond this range. ICS also designates specific facilities for operational purposes and manages the deployment and assignment of resources. All resources, including personnel, are tracked in real time to ensure full accountability.

ICS standardizes communication across organizations by establishing common terminology, thereby facilitating more straightforward and more effective interactions. For larger incidents, a specialized communications unit may operate under the logistics section. (Source: Cybersecurity and Infrastructure Security Agency, no date)

Formal procedures govern the establishment and transition of command, with a clearly defined chain of command. Agencies responding to an incident are expected to collaborate to form a unified command structure. Information flows in an organized manner from individual responders to command staff, providing a comprehensive overview of the response and enabling more effective management.

ICS has been used successfully in disaster response, including within hospital systems during the COVID-19 pandemic.[9] Law enforcement agencies have widely implemented NIMS principles, which demonstrate applicability to certain response types. However, adoption often occurs after the initial incident phase.[10] NIMS and ICS procedures have also been used to train physicians for in-hospital rapid response, with reported positive outcomes.[11]

In contrast, during the Boston Marathon Bombing, the incomplete implementation of specific ICS components was associated with operational challenges observed during the response. (Source: Duggan et al, 2023) Within the US, 2nd- and 3rd-cycle responders, including the transportation sector, have experienced delays and challenges in implementing NIMS. Reported barriers include limited understanding of NIMS applicability, funding constraints, and system complexity. (Source: Hambridge et al, 2017)

Clinical Significance

Disaster planning is fundamental to effective disaster response and begins well before an event and continues throughout the response phase. Despite the recognized importance of preparedness, the US allocates a relatively small proportion of total health expenditures to prevention programs for public health emergencies, which represent a critical component of disaster preparedness and planning.[12]

Planning activities intensify when a disaster threat, such as an approaching hurricane, becomes imminent. Initial planning focuses on situational assessment, including anticipated resource requirements, available assets, and the potential scale of the event. Based on this assessment, incident objectives are established to guide the response. These objectives are then translated into an overall plan that defines response tactics and resource allocation strategies.

Response planning incorporates both fixed factors, which remain consistent across disaster types, and variable factors that depend on the specific event. These considerations are integrated with additional influences on response operations, including evacuation decisions. (Source: Iman et al, 2023) The document is distributed and activated following plan completion. Continuous evaluation and revision occur throughout the response, a process commonly referred to as the planning “P.”

Even in the absence of an imminent disaster, proactive planning for potential events remains essential. Long-term planning at the community level begins with the completion of a hazard vulnerability analysis (HVA). The initial step involves identifying specific hazards. Geographic features such as dams, fault lines, and terrain characteristics that may limit access to portions of the service area require assessment. Climatic conditions also warrant consideration, including seasonal variations and weather patterns that may affect Emergency Medical Services (EMS) operations. Additional factors include the local economic environment and community crime statistics.

For each identified hazard, planning should account for historical occurrence, potential impacts on vulnerable populations or areas, and the estimated likelihood of occurrence, including pandemics and infectious disease outbreaks. During the COVID-19 pandemic, use of HVAs with targeted mitigation strategies demonstrated effectiveness.[13] Artificial intelligence–based platforms have also shown potential utility in conducting HVAs.[14] The integration of these elements yields a comprehensive community HVA.[15]

Staff education for disaster events is a critical component of the planning process and is frequently identified as a deficiency in preparedness. Although staff education is not typically incorporated into an HVA, inadequate training may constitute a significant vulnerability within a disaster plan. Effective disaster response depends, in part, on a workforce prepared to operate under austere, rapidly evolving conditions.

A 2021 literature review identified insufficient disaster preparedness among the majority of healthcare workers.[16] Assessing staff preparedness, knowledge, and readiness within healthcare settings presents methodological challenges. The Disaster Management Assessment Tool for Health Care Practitioners (DMAT_HCP) has been developed, evaluated, and demonstrated to be a reliable and effective instrument for measuring disaster-related knowledge among healthcare personnel.[17]

Structured disaster management training programs have been shown to improve disaster response readiness among hospital-based nurses.[18] Ongoing education in disaster preparedness and response remains essential among personnel most likely to encounter no- or low-notice disaster events, including emergency nurses and EMS clinicians.[19][20] Despite this need, both professional groups are insufficiently prepared for disaster events, according to multiple studies.[21][22] (Source: Tas and Cakir, 2022)

Emergency operations plans (EOPs) are developed both before and at the onset of disaster events and should reference NIMS while incorporating ICS principles. The EOP outlines the disaster response framework for participating agencies and is designed to remain flexible and scalable in response to incident demands. The plan addresses needs generated by the specific disaster type and requirements arising from response operations. (Source: Canton, 2022)

Phased planning allows the EOP to be adapted to different operational stages. Branching within the plan supports the development of multiple contingency options to address variations in disaster impact. The EOP includes explicit criteria for plan activation and identifies the individual or position authorized to initiate implementation, typically the highest-ranking staff member on duty.

The plan defines the command chain and establishes mechanisms for coordination with external agencies. Provisions for the protection of persons and property are included, with specific consideration for vulnerable populations, including children and adults with disabilities. Planning for uninjured children, particularly those separated from caregivers, is also addressed.

Resource identification constitutes a core component of the EOP. Personnel, supplies, facilities, equipment, and other assets available within the jurisdiction are specified, along with external resources secured through preexisting agreements, including federal support. Interagency coordination and mutual-aid requirements are formalized through written agreements. Mitigation strategies during the response phase and considerations for recovery operations are incorporated into the plan.

Several recurrent deficiencies are observed in EOP development. One of the most frequent errors involves the creation of plans that are excessively detailed or overly lengthy, limiting usability during operations. Consideration of the full spectrum of the community, including vulnerable populations, is often insufficient. Community-wide capabilities are frequently overlooked, with planning efforts focused primarily on trained emergency responders rather than inclusive response assets. Another common deficiency involves reliance on inaccurate or incomplete assessments of hazards, available resources, or organizational competencies.[23]

The EOP defines the requirements necessary for effective disaster response management. These requirements inform the scope and structure of training and exercise programs needed to achieve preparedness, thereby establishing agency-specific training priorities. Exercises extend this process by validating response plans and procedures while assessing personnel performance and skill levels. Internal exercises and joint drills with partner organizations help identify interoperability training gaps. (Source: FEMA, 2025)

Identified performance deficiencies may be addressed through targeted training, acquisition or modification of equipment, and revision of procedures or interagency agreements. The EOP functions as a living document and requires periodic revision to address deficiencies identified during real-world responses or exercises attributable to the plan.